Dr. Jeff Hersh: A consent form could save your life

Tuesday

Feb 4, 2014 at 2:06 PMFeb 4, 2014 at 2:06 PM

By Dr. Jeff HershMore Content Now

Q: Why did my doctor have me sign a consent form? She recommended I have the test done, so what choice did I really have?A: Looked at in a very simple way, the practice of medicine is the application to patient care of a benefit versus risk analysis.To assess possible risks a healthcare provider (HCP) evaluates their patient to determine the probability that they have a medical condition (or conditions) and the possible severity and consequences the condition may pose. The HCP must also factor in any potential adverse consequences of diagnostic tests and/or treatment plans that may be considered.The benefit side of the analysis derives from the minimization or avoidance of the possible medical consequences of the condition(s) being considered.Thus, we can summarize the HCP’s initial role as performing an appropriately focused history and physical exam and then weighing the overall potential benefits versus the overall potential risks in order to recommend a care plan they think is in the best interests of their patient. Possible recommendations include:• Treatment risks continue to be minimized through improvements in therapeutic options, such as the advancements made to utilize minimally invasive procedures instead of open procedures (when appropriate). Improvements in the risk/side effect profiles of many medications also reduce the risk to patients.• Technological advancements continue to minimize many of the risks of diagnostic testing; for example the radiation dose from today’s generation of CT scanners is considerably lower than it was from the state of the art CT scanners of as recently as several years ago.The benefit side of the analysis derives from the minimization or avoidance of the possible medical consequences of the condition(s) being considered.• As more efficacious treatment options become available the potential to increase the patient’s quality and/or quantity of life increases.Screening is becoming more important as treatments are developed that may cure conditions previously considered fatal, especially if they are identified early enough.• Watchful waiting; that is, no immediate diagnostic tests (beyond any that have already been done) and no immediate treatment is recommended, the goal being to gather more information by seeing if and how things change over time.• Actively gathering further diagnostic information by doing additional testing. This includes performing screening tests on asymptomatic patients to diagnose subclinical diseases while they are in a stage where treatment may be most beneficial.• Immediate treatment.• Some combination of all of these.Each patient is different, so their benefit versus risk assessment must be made specifically for them. For example, a recommendation to watch and wait versus do further testing may be different for a young healthy adult than for an immune-compromised elderly patient. Or a young healthy patient just returning from a month of volunteer work in Nigeria may benefit from tests that would otherwise not be indicated.Diagnostic testing and disease screening have saved countless lives and enabled treatments to improve the quality of life for countless others. Because of this, the benefit/risk evaluation by many clinicians often leans more strongly towards diagnostic testing than for a watch-and-wait plan.All HCPs hear the adage “when you hear hoof beats, don’t initially think of zebras” many times during their training. This refers to the fact that zebras are uncommon (at least in the United States), and we should consider more common things (like horses) before considering rare or unusual things. However, the threat of malpractice litigation in the U.S. has affected how many HCPs practice medicine, and the search for “zebras” (rare conditions) too often contributes to care plans they recommend (known as defensive medicine).HCPs must continue to work with each of their patients on a case-by-case basis to create the best care plan possible, basing this on the overall benefit/risk assessment. However, decisions are seldom black and white; one person may look at a benefit/risk evaluation and decide the benefit outweighs the risk, whereas someone else may look at the same assessment and come to a different conclusion. Therefore, the final decision as to which treatment plan is best must be made by the patient themselves, in close consultation with their HCP.Consent is obtained for certain procedures to document that the benefit/risk evaluation has been discussed and to empower the patient by making it clear the final decision is theirs. In addition, getting consent (or having it refused) offers some protection to the HCP against litigation should one of the risks discussed with the patient manifest.Jeff Hersh, Ph.D., M.D., can be reached at DrHersh@juno.com.